Paying for Propofol During Colonoscopy
Eyeing New Devices and Drugs, Aetna Postpones Propofol Policy
Aetna, the third-largest U.S. health insurer, is backing off of its earlier announcement that it will no longer pay for monitored anesthesia care for routine colonoscopies — but only until the FDA approves patient-friendly alternatives to anesthesiologist-monitored sedation services.

Although Aetna wouldn't name the new approaches it had in mind, it's no secret that the FDA is reviewing both a medical device and a sedative which can provide the same experience as monitored anesthesia, but can be controlled by the gastroenterologist performing the procedure. Both could be approved later this year.

• Ethicon Endo-Surgery is seeking clearance to market a computer-assisted sedation device (pictured) which would eliminate the need for an anesthesiologist to administer propofol for colonoscopies. CAPS (computer-assisted personalized sedation) combines continuous physiological and sedation monitoring through an electronic interface with software to facilitate precise control of drug delivery, says Ethicon.
• MGI Pharma is seeking approval for Aquavan, a variant on propofol that has been administered by nurses without the help of anesthesiologists in its clinical trials. Aquavan has completed one phase 3 trial in which it successfully met its primary endpoint of sedation success in a study of patients undergoing colonoscopy, says MGI Pharma. A phase 3 program is underway.

Aetna said in December that it would stop paying for the use of propofol in routine cases as of April 1 because research showed the participation of an anesthesiologist added $300 to $1,000 to the screening costs without improving outcomes. Critics countered that restricting the use of propofol would discourage patients from undergoing a colonoscopy. Propofol is considered a preferred sedative for endoscopy patients due to its rapid onset and quick, clear-headed recovery.

— Nathan Hall

Trends in the ASC Sector
Highlights from Deutsche Bank's second annual ambulatory surgery center survey, based on responses from more than 200 ASCs:

• Respondents expect case volume growth of about 3 percent in 2008, down from the 5 percent they forecast in 2007.
• Respondents expect revenue per case growth of about 2 percent in 2008.
• Forty-five percent of respondents expect more competition to enter their local markets in 2008. However, assuming that the average ASC has 20 to 25 active surgeons, Deutsche Bank analysts argue that the supply of surgeons currently not affiliated with an ASC could limit de novo development.
• When asked about the impact of Medicare's ASC payment changes, 35 percent expected it to be positive, 30 percent negative and 35 percent neutral.
• The average number of ORs and procedure rooms per facility was 3.9. Chain-affiliated ASCs averaged 4.3 ORs and procedure rooms vs. 3.8 for non-chains.
• The average facility performs 360 surgical procedures monthly, which equates to about 4,200 annual procedures.
• The average ASC partnership had 15.1 physician-partners and 24 total physician-users, a slight decrease from last year (16.5 physician-partners and 28.2 credentialed physicians).

— Dan O'Connor

No Cherry-picking in the Beehive State
Utah ASCs and Hospitals Battle for Medicaid Business
Utah ASCs are fighting hospitals and health insurers for more access to the state's 20,000 Medicaid cases. Currently, less than half of Utah's 50-plus ASCs have contracts with at least one of the state's three Medicaid managed care organizations. "The goal is to allow surgical centers to participate in all Medicaid plans," says Brian Berg, administrator at the Mountain West Surgical Center in Bountiful, Utah, and treasurer of the Utah Ambulatory Surgery Center Association. "We're trying to quash the rumor that we're not willing to take that patient mix."

The Utah ASC Association has been working with Republican State Senator Allen M. Christensen, DDS, with mixed results, to change Utah law so that any ASC can take Medicaid cases. Unlike many other states, Utah's Medicaid program is managed by three health insurance companies. Mr. Berg says that the insurers restrict access to their networks in favor of hospitals.

"They're not being excluded any more than hospital-owned surgery centers," says Dave Gessel, vice president of government relations and legal affairs for the Utah Hospitals and Health Systems Association. He says only one-fourth of the 12 hospital-owned surgery centers have Medicaid contracts.

In January, Sen. Christensen introduced a bill (SB 82) that would require the state's Medicaid program to include ASCs as providers. Last month, the senator proposed a directive to create a two-year pilot program in which any ASC could take Medicaid-approved ophthalmic and ear-nose-throat cases.

Molina Healthcare of Utah calls the pilot program "forced contracting" that would benefit only the ASCs that haven't made an effort to negotiate contracts with the Medicaid health plans.

Medicaid reimbursement is about 77 percent of billed charges, says Mr. Berg. Utah hospitals performed 15,000 Medicaid procedures in 2005, at an average per-case cost of $2,600. ASCs performed 5,000 Medicaid procedures at an average cost of $1,850 per case, records show.

— Kent Steinriede

Office Surgery Safety Under Scrutiny
Seven years of prospective data on office surgery incidents in Florida show that about half of the 31 deaths and 143 procedure-related complications and hospital transfers resulting from office surgery incidents between 2000 and 2007 involved cosmetic procedures performed by board-certified plastic surgeons administering general anesthesia, says a study published in Dermatologic Surgery.

Liposuction procedures, performed either alone or in conjunction with abdominoplasty or other cosmetic surgeries, resulted in eight of the 31 deaths — they were the most common cause of death — and 24 cases of complications. Seven of the eight patients who died were administered general anesthesia. Four of the deaths were attributed to pulmonary emboli and three to unknown causes. All eight patients died several hours to nine days following uneventful discharges.

"All cosmetic procedures except abdominoplasty can be performed under local anesthesia, albeit with less convenience for the patient and surgeon," the researchers write.

Meanwhile, Arizona has enacted new regulations for doctors who perform office-based surgeries outside of hospital or ASC settings using sedation. The rules state that offices must be equipped to perform the procedure safely, to administer and monitor sedation and to rescue a patient who enters a deeper state of sedation than intended.

— Dan O'Connor

In the Know

• Workweek Idea Wins Apple iPod. Of the 55 time- and money-saving ideas our readers submitted in response to a survey for the "It's Good to Be Frugal" feature story in our February issue, we crowned one to be the most ingenious. "Behold, the 4-day Workweek," submitted by Rosalind J. Loyd-Chisley, RN (shown below seated amongst her staff) described how, on a rotating basis, five members of a 10-person nursing staff work four 10-hour days, then take either Monday or Friday off. To thank Ms. Loyd-Chisley, the ambulatory surgery supervisor at the LSU Health Science Center in Monroe, La., for sharing her idea, we sent her a 4GB Apple iPod Nano.
• Most Children Suffering From Obstructive Sleep Apnea benefit from tonsillectomy and adenoidectomy, says Ron Mitchell, MD, professor of pediatric otolaryngology at Saint Louis University. In a study in the October 2007 Laryngoscope, Dr. Mitchell reports that all 79 patients studied showed significant improvement in OSA symptoms after surgery. However, only those with mild sleep apnea, marked by five to nine interrupted breathing incidents per night, experienced post-op resolution of OSA. Eighty-eight percent of children with moderate OSA (10 to 19 incidents per night) experienced resolution; 64 percent of patients suffering severe OSA (20 or more sleep interruptions per night) had the condition resolved.
• Healthcare workers who repeatedly wash their hands are at increased risk for hand dermatitis, says Susan Nedorost, MD, FAAD, associate professor of dermatology at University Hospitals Case Medical Center in Cleveland, Ohio. She presented her findings at the American Academy of Dermatology's annual meeting last month. Two things you can do: Substitute alcohol-based hand cleansers for hand washing and apply a cream or ointment-based emollient immediately after water exposure, before the skin is completely dry.